Brain Injury Matters Solicitor Affiliation Awareness Programme

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1 The will provide users of with access to a list of solicitors in Northern Ireland that have completed an Awareness on Acquired Brain Injury and demonstrate key quality indicators which show adherence to good practice. The programme will enhance skills and knowledge of those solicitors working with clients with Acquired Brain Injuries and generate vital income for service development. Affiliated solicitors will feature on the website and the quarterly newsletter, reaching a diverse range of individuals affected by Acquired Brain Injury, including survivors, carers, health professionals and volunteers. All solicitors applying for inclusion on Affiliation must: Have Professional Indemnity Insurance Cover Meet Disability Discrimination Act 1995 requirements Attend our annual training on brain injury Agree to a fee of 500 per annum.

2 Firm Details Name of Firm: Address of Office Submitted for Contact Solicitor: Postcode: Tel: Fax : (this will appear on the List) Website: Contact Solicitor Details: Contact Name Contact (if different to above) Position Date of Qualification Solicitors Roll No. Section 2: Solicitor/Firm Training Background 1. How long have you practised in personal injury work since qualification? (please attach your Continuing Professional Development (CPD) records detailing all training undertaken over the past year) _ Please note 5 years is a minimum requirement 2. No. of partners in the firm 3. No. of associate solicitors in the firm 4. No. of additional fee-earners in the firm 5. No. of fee-earners with personal injury responsibilities 6. No. of fee earners with experience of managing brain injury cases

3 7. Please provide/illustrate case account example(s) over the past 5 years:

4 8. As a solicitor and as a firm, is the make up of your caseload: Solicitor Firm Mainly Claimant? Y/N Mainly claimant? Y/N Mainly defendant? Y/N Mainly defendant? Y/N Both? Y/N Both? Y/N 9. Are you prepared to visit brain injured clients at their home? Y/N 10. Are you willing to travel to clients outside of your local area? Y/N 11. Does your office have wheelchair access? Y/N 12. Are you, the Contact Solicitor, a member of the AVMA? Y/N 13. Are you a member of APIL? Y/N 14. Does your firm have corporate APIL accreditation? Y/N 15. Are you, the Contact Solicitor, or any other fee-earner in your firm accredited by the APIL as: Litigator Y/N Senior Litigator Y/N Fellow Y/N 15. Is your firm Lexcel or ISO accredited? Y/N Please specify:

5 Section 3: Insurance Please attach a photocopy of your professional indemnity insurance cover certificate. It must be 10,000,000 or over. Section 4: Complaints Until this is received we are unable to process your application. 1. Do you have a complaints procedure for clients? (If so, please provide a copy) Y/N 2. In the past 3 years, has your firm been the subject of a complaint to the Law Society NI in relation to a brain injury claim? If yes, please provide details: _ Declaration I confirm that all the information I have provided in this application is correct. Print name: Signature: Date: / / Headway Suite Belfast 5C Stirling House Suite 5C Castlereagh Stirling House Business Park Castlereagh 478 Road 478 Castlereagh Road